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Authorization for Disclosure of
Protected Health Information to Third Parties

(i.e. Department of Public Health, Employer, Physician)

Patient Information

Release Information

By completing this form you are authorizing Genentox Laboratories LLC dba Nova Diagnostics Laboratories to release your SARS-CoV-2/COVID-19 RT-PCR test results to third party entities such as government offices, the Department of Public Health, your employer and/or the ordering physician.

Purpose of Release

This authorization will allow Genentox Laboratories LLC dba Nova Diagnostics Laboratories to disclose my SARS-CoV-2/COVID-19 test results with select third parties. I understand this consent is voluntary and that I may refuse to sign. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my test results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider.

Information to be Released

Medical Information. Any lab test results relating to SARS-CoV-2/COVID-19 testing, including "back to work" recommendations.

Service Dates. Any dates of services rendered from the date I sign this form and one year forward.

Expiration/Effective Dates. This consent will expire one year from the date I sign it. This authorization applies to any lab tests results related to COVID-19 screening/testing after the date of my signature. I may revoke this consent at any time by sending written notice to Genentox Laboratories LLC dba Nova Diagnostics Laboratories.

To the fullest extent permitted by law, I hereby release, discharge and hold harmless Genentox Laboratories LLC dba Nova Diagnostics Laboratories — without limitation — and it's respective officers, directors, employees ,representatives and agents, from any and all claims, liability and damages of whatever kind or nature, a rising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results to a third party.